CLAIM FOR DAMAGES RESERVE. FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No. -
INSTRUCTIONS RECEIVED
Claims for death, injury to person or to personal property must be filed not later than six (6) months after the occurrence. (Gov. Code Sec. 9112)
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence. (Gov. Code Sec.911.2) JAN 2 7 2025 3: - Read entire claim before filing.
See page 2 for diagram upon which to locate place of accident
5. This claim form must be signed on page 2 at bottom. CITY CLERK DEPARTMENT
6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET
7. Claim must be filed with City Clerk. (Gov.Code Sec. 915a) TO: CITY OF VERNON CITY COUNCIL
Name of Claiman Age of Claimant (If natural person)
MelviN 72
Gilviand Statel Home Telenhone Number
Business Address of Claimant re City and State Business Telephone Number Give address to which you desire notices or communications to be sent regarding this claim:
He did ME or NURY occur? Give full particulars. I was dries west bourd ON WAshIngtON BleC. AfteR pASSI INdIANA 3T.
ot hole that edented Achoss the Rond i 1 hut t
tine's on the deepers side Front& BacKankeet bolY. Rves When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
the
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
4924G
WAshwes westbound About 25 yards pass → ENdiANA
carinatie inar missionowyou daim causedthe injury or damage? Givenames of hyemployes, if any.. causing the injury or damage, if known:
Pot hole's cause the dansge
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Twi Blown tines Two dAMaged Ruis
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
TiRes $ 80.00 Apiece Lobor #100.00
Give ESTIMATED AMOUNT as faras knownyou claim on account of each item of prospective injury or damage, giving basis of computation:
-BF $,258,00gvim
AЗ : LE
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
No
Expenditures made on account of accident or Injury: (Date - Item) (Amount) New KIMS RepAIri 812500
Name and address of Witnesses, Doctors and Hospitals:
N/A
READCAREFULLY
For all accident claims place on following diagram names of streets, including North, East. South, and West: indicate place of accident by "X" and by showing house numbers or distances to street corners.
If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw City vehicle; location of City vehicle at time of accident by "A-1" and location of yourself or you vehicle at the time of accident by "8 1" and the point of Impact by "X." NOTE:If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
West bour
vashington
71T,
FOR OTHER ACCIDENTS
////
CURB!
CURB,
PARKWAY
SIDEWALK
I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Typed/Printed Name: Signature of Claimant or person filing on his/her behalf, giving Date:
relationship to Claimant:
1/22/2025
S TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CAL PEN. CODE SEC. 72) CLAIMS MUST BE FILEDWITH CITY CLERK (GOV.CODE SEC. 915a). STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF ANY ACTION BY THE CITY OF THIS CLAIM WITHIN 45 DAYS OF FILING THEN THE CLAIN IS DEEMED DENIED (SEE GOV. CODE SEC. 911.6 & 912.4) Rev. 8/4/16
NAME PHONE CUSTOMER
MEXICO TIRES
New and Used Tires-General Mechanic/Mecanica en General ADDRESS CITY 4825 E. Florence Ave. Bell CA 90201
(323)560-5554 STATE ZIP DATE
www.mexicoautorepairbell.com 3-2015
MATERIAL ALL PARTS NEW UNLESS SPECIFIED U-USED, R- REBUILT, RC- RECONDITIONED
WARRANTY
QTY PART No. NAME OF PART PRICE CUSTOMER'S INFORMATION
RECEIVED (DATE&TIME) AM CUSTOMER ORDER No. LICENSE No.
PM
YEAROOLe MAKE MODEL 2 S. 7.2 ODOMETER
LUBE OIL CHANGE FLUSH TRANS FLUS-TH DIFF
CHARGE FOR HAZARDOUS OR OTHER WASTE REMOVAL*
KEPAR
whee ASSUMEN
METHOD OF PAYMENT LABOR DAY 1060
[CHECK • CHARGE TO DAS
PARTS 110
• CASH ACCESSORIES
FASTEn Yen
MECHANIC RECOMMENDATIONS GAS, OIL & GREASE
LABOR
[FLAT RATE • HOURLY MISC. MERCHANDISE
• вотн SUBLET REPAIRS
STORAGE FEE
• RETAIN PARTS
• DESTROY PARTS TAX
Estimate cost $ Estimate Charge Basic for Change
AUTHORIZED BY
TOTAL 250:0
PLEASE READ CAREFULLY, CHECK ONE OF THE STATEMENTS BELOW, AND SIGN I UNDERSTAND THAT, UNDER STATE LAW, I AM ENTITLED TO A WRITTEN ESTIMATE, INCLUDING A COMPLETION DATE, IF MY You are entailed by law to return of the all parts replaced, except those for which there is a core charge. Unless FINAL BILL WILL EXCEED THIS 4100($50 IN MD) You agree otherwise by initialing the following _ _I do not desire the return of any parts that are -I REQUEST A WRITTEN ESTIMATE, THE FINAL BILL MAY NOT EXCEED THIS Replaced during the authorized repair.
ESTIMATE WITHOUT MY WRITTEN APPROVAL
Estimate good for 30 days, Not responsible for damage caused by theft, fire, or act of nature. / authorize _I DO NOT REQUEST WRITTEN ESTIMATE, AS LONG AS THE REPAIR COST DO NOT EXCEED The above repair, along with any necessary materials. I authorize you and your employees to operate my THE SHOP MAY NOT EXCEED THIS AMOUNT WITHOUT MY WRITTEN OR ORAL APPROVAL Vehicle for the purpose of testing, inspection, and delivery at my risk. An express mechanic lien is hereby —I DO NOT REQUEST A WRITTEN ESTIMATE Acknowledged on the above vehicle to secure the amount of repair thereto if I cancel repairs prior to their Completion for any reason, a tear, a tear-down and reassembly fee of s. _ will be applied *Checked lines apply (Preparer must check at least one) SIGNED - This change represents costs and profits to the motor vehicle repair facility for miscellaneous shop supplies or waste disposal - This amount includes a charge of. _ which is required under.. law DATE
RO
ST
Indiana
MMERCE
Indiana